Social Needs Screening Process

• Who within your organization will be responsible for conducting social needs screenings and referral?
• What social needs screening tool(s) will you utilize?
  • Additionally, you can leverage existing resources such as LinkU, which offers a built-in Social Needs Screener to streamline the screening process and ensure comprehensive data collection. LinkUDMV Standard Needs Assessment
• Which clients or populations will be screened? Will screening be universal or focused?
• How frequently will screenings occur? (Consider factors like client risk, program requirements, and available resources.)
• How will screening results be documented and stored? (Ensure compliance with data privacy regulations.)

• LinkU [linkudmv.org] is a free on-line resource and referral guide. Search for free and reduced-cost services, like medical care, food, housing and more in the DC Metropolitan Area.
• LinkU contains a built-in Social Needs Screener that can be completed by residents or staff.
• The platform, with the screener information, LinkU will curate a referral list for the resident based on reported needs.

Best Practices for Effective Social Needs Screening

1. Ensure Cultural and Linguistic Appropriateness: Tailor screening tools and staff communication to reflect the diverse backgrounds of your clients.
2. Address Bias and Stigma: Train staff to conduct screenings in a sensitive, non-judgmental manner.
3. Empower Client Participation: Explain the screening process clearly and emphasize its importance in providing holistic care.
4. Provide Staff Training and Support: Equip staff with the knowledge and skills to conduct screenings and effectively discuss the referral process with residents.
5. Accommodate Diverse Needs: Adapt the screening process for clients with limited literacy, cognitive impairments, or disabilities.
6. Prioritize Confidentiality: Strictly adhere to data privacy regulations and protect client information.
7. Link Results to Care Plans: Use screening results to develop individualized care plans and connect clients to appropriate resources.
8. Establish Follow-Up Procedures: Ensure regular follow-up with clients who screen positive for social needs.

Recommendations

• Leverage LinkU: Use LinkU [linkudmv.org] to streamline screening, resource identification, referral tracking, and evaluation processes.
• Maintain Up-to-Date Resource Inventory: Regularly update your internal and external resource lists to ensure accuracy and relevance.
• Utilize Centralized Databases: Use platforms like LinkU to centralize resource information and facilitate staff access.
• Collaborate with Community Partners: Build strong relationships with other organizations to expand your capacity to address diverse social needs.
• Track and Evaluate Outcomes: Monitor referral success rates, client satisfaction, and changes in social determinants of health.

Monitoring and Evaluations Recommendations

• Track the number of clients screened, referrals made, and successful connections to services (close the referral loop).
• Measure client satisfaction with the referral process and service outcomes.
• Monitor changes in client well-being and social determinants of health over time.
• Evaluate the cost-effectiveness of social needs interventions.
• Use data to identify barriers to service

Definitions                         

• Closing the Referral Loop: Ensuring that clients not only receive referrals but also successfully access the services they need. This involves following up to confirm that clients have connected with the referred services and received the appropriate support, ensuring that no client falls through the cracks after the initial referral.(1)
• Cultural competency: Understanding and respecting different backgrounds, beliefs, and ways of doing things. Understanding that people from different countries may have different holidays or favorite foods. (2)
• Holistic Care: Caring for the whole person means nurturing their body, mind, and emotions, not just addressing a single issue. It’s like taking care of a plant —not only watering it but also ensuring it gets sunlight and nutrient-rich soil. (3)
• Language access: Making sure everyone can understand important information. This means having translators and documents in different languages. It’s like having a book in different languages so everyone can read the same story. (4)
• Limited English Proficiency (LEP): People who do not speak English as their primary language and who have a limited ability to read, write, speak, or understand English. These individuals are entitled to language assistance services to ensure meaningful access to programs and activities funded by the federal government. (5)
• Plain Language: Using words and language that everyone can easily understand and offering help with translation for those who need it. (6)
• Social Needs: Non-medical factors that influence health outcomes, such as access to food, housing, economic stability, education, health care access and quality, and neighborhood and built environment. (7/8)

Example